1. JAMA. 2016 Aug 9;316(6):611-24. doi: 10.1001/jama.2016.10708.

Association of Noninvasive Ventilation Strategies With Mortality and
Bronchopulmonary Dysplasia Among Preterm Infants: A Systematic Review and

Isayama T(1), Iwami H(2), McDonald S(3), Beyene J(4).

Author information: 
(1)Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario,
Canada2Department of Newborn and Developmental Paediatrics, Sunnybrook Health
Sciences Centre, Toronto, Ontario, Canada.
(2)Department of Neonatology, Osaka City General Hospital, Osaka, Japan.
(3)Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario,
Canada4Department of Obstetrics & Gynecology, McMaster University, Hamilton,
Ontario, Canada5Department of Radiology, McMaster University, Hamilton, Ontario, 
(4)Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario,

Erratum in
    JAMA. 2016 Sep 13;316(10):1116.

IMPORTANCE: Various noninvasive ventilation strategies are used to prevent
bronchopulmonary dysplasia (BPD) of preterm infants; however, the best mode is
OBJECTIVE: To compare 7 ventilation strategies for preterm infants including
nasal continuous positive airway pressure (CPAP) alone, intubation and surfactant
administration followed by immediate extubation (INSURE), less invasive
surfactant administration (LISA), noninvasive intermittent positive pressure
ventilation, nebulized surfactant administration, surfactant administration via
laryngeal mask airway, and mechanical ventilation.
DATA SOURCES: MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL from their inceptions
to June 2016.
STUDY SELECTION: Randomized clinical trials comparing ventilation strategies for 
infants younger than 33 weeks' gestational age within 24 hours of birth who had
not been intubated.
DATA EXTRACTION AND SYNTHESIS: Data were independently extracted by 2 reviewers
and synthesized with Bayesian random-effects network meta-analyses.
MAIN OUTCOMES AND MEASURES: A composite of death or BPD at 36 weeks'
postmenstrual age was the primary outcome. Death, BPD, severe intraventricular
hemorrhage, and air leak by discharge were the main secondary outcomes.
RESULTS: Among 5598 infants involved in 30 trials, the incidence of the primary
outcome was 33% (1665 of 4987; including 505 deaths and 1160 cases of BPD). The
secondary outcomes ranged from 6% (314 of 5587) for air leak to 26% (1160 of
4455) for BPD . Compared with mechanical ventilation, LISA had a lower odds of
the primary outcome (odds ratio [OR], 0.49; 95% credible interval [CrI],
0.30-0.79; absolute risk difference [RD], 164 fewer per 1000 infants; 57-253
fewer per 1000 infants; moderate quality of evidence), BPD(OR, 0.53; 95% CrI,
0.27-0.96; absolute RD, 133 fewer per 1000 infants; 95% CrI, 9-234 fewer per 1000
infants; moderate-quality), and severe intraventricular hemorrhage (OR, 0.44; 95%
CrI, 0.19-0.99; absolute RD, 58 fewer per 1000 births; 95% CrI, 1-86 fewer per
1000 births; moderate-quality). Compared with nasal CPAP alone, LISA had a lower 
odds of the primary outcome (OR, 0.58; 95% CrI, 0.35-0.93; absolute RD, 112 fewer
per 1000 births; 95% CrI, 16-190 fewer per 1000 births; moderate quality), and
air leak (OR, 0.24; 95% CrI, 0.05-0.96; absolute RD, 47 fewer per 1000 births;
95% CrI, 2-59 fewer per 1000 births; very low quality). Ranking probabilities
indicated that LISA was the best strategy with a surface under the cumulative
ranking curve of 0.85 to 0.94, but this finding was not robust for death when
limited to higher-quality evidence.
CONCLUSIONS AND RELEVANCE: Among preterm infants, the use of LISA was associated 
with the lowest likelihood of the composite outcome of death or BPD at 36 weeks' 
postmenstrual age. These findings were limited by the overall low quality of
evidence and lack of robustness in higher-quality trials.

DOI: 10.1001/jama.2016.10708 
PMID: 27532916  [Indexed for MEDLINE]